Have You Been 'Downcoded'?

By L.A.S.

It you have been 'downcoded' (this is a practice in which insurance companies revise a claim made by a doctor or hospital with a lower-price procedure instead of the higher-price procedure submitted by the health care provider), could you please leave a comment with how to reach you? The people at Huffington Post are trying to further investigate this practice, but they need documents, or some kind of source material, to work with.

In Honor of the Upcoming Veterans Day – How To Make Claims on Your Military Life Insurance

In honor of Veterans Day this year, I want to help the families of military veterans get their proper benefit checks for life insurance policies held by service persons. IF you have kept up your military group life insurance policy during service (if still in uniform) or after discharge, you (or rather your beneficiaries) should be able to get the VA to accept your claim. Just read this article and go to the link given below to find the claim form.

Several years ago a scandal broke out about the Veterans Administration denying all phone inquiries inre making claims on veterans group life insurance policies. It seemed that the staff was using the funds to pay for department parties and other nonsense.

I was also surprised to hear of one widow of a WWII veteran making a successful claim on her late husband's policy not long before this scandal broke out (about ten years ago). Fortunately for her, she had an adult child who sent in a request for a claim form instead of just accepting the erroneous information that had been received by phone. The veteran had kept policy status updates on file, and so they had a policy number and an address to send the request to.

So to make a long story short, they received the claim form – a mere half-page long – and filled in the necessary information. The only difficult section asked for the veteran's discharge date, an item they luckily had on the discharge papers.

Do you want to guess how much money the widow wound up with? The policy had been paid up some time before and was accruing interest. The final valuation was for over $6200. That was a very welcome hunk of change to help make up for the loss of her husband's pension check from work.

Below is the link to the VA insurance page. There are several forms available but to make a claim, click on the one that says: SGLV 8283, Claim for Death Benefits. There is also a related form to make claims for the death of a spouse (or other covered family member) of a military service person.
http://www.insurance.va.gov/sgliSite/forms/forms.htm

It does not matter how long ago your military service person or veteran died; the policy still accrues value until the claim is made. Just dig up your insurance policy and discharge papers, and you will have enough information to fill out the claim form.

Good luck to all of you, and thank you to all our United States veterans out there (and their families). Have a good day.

[The erroneous information given by phone was possibly a mixup; the VA continually has to deny inquiries about a mythical veterans insurance dividend payout. You can read a full article explaining that confusing urban myth at http://urbanlegends.about.com/library/weekly/aa050698.htm .]

Wall Street Journal Has Story on Fighting Insurance Denials

Pushing Back When Insurers Deny Coverage for Treatment --
By Anna Wilde Mathews, The Wall Street Journal
http://www.marketwatch.com/News/Story/Story.aspx?guid=b6e08398424d449bb8ac46fc3c8a2565&siteid=nwtpf&sguid=LlOmLCZmMkSOlLZa0_8Pmw
Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to join the growing number of people who are appealing coverage denials, there are several strategies that can bolster your case.

RECOMMENDED READING AND SOURCES:

RECOMMENDED READING AND SOURCES:


“Accounting for the Cost of Health Care in the United States,” McKinsey Global Institute, http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp

Alzheimers Reading Room, web log with a variety of info for caregivers, http://alzheimersreadingroom.blogspot.com/2007/08/training-helps-alzheimers-caregivers.html

Appeal letters available for a fee at Health Symphony website, http://www.healthsymphony.com/

Barton, Laura, “A hug a day keeps the doctor away,” The Age, July 31, 2007, http://www.theage.com.au/news/health/a-hug-a-day-keeps-the-doctor-away/2007/07/31/1185647872383.html?page=fullpage#contentSwap1

Bazell, Robert, “The costly side effects of Nexium's ad blitz” MSNBC.com, Aug 14, 2007, http://www.msnbc.msn.com/id/20249591/

Bolen, Jennifer, “Exposing the Department of Health and Human Services/American Medical Association Health Care Monopoly”, Townsend Letter, Feb-March 2007 issue, http://www.townsendletter.com/FebMarch2007/exposeama0207.htm

Boseley, Sarah, Government warning on DIY cancer treatments, The Guardian, April 28, 2008, http://www.guardian.co.uk/society/2008/apr/28/health.cancer.

Boseley, Sarah, “NHS GPs at new Virgin health centres will get 10% of profits”, The Guardian, April 9, 2008, http://www.guardian.co.uk/society/2008/apr/09/nhs.health2

Boseley, Sarah, “Three more deaths at 'special measures' maternity hospital”, The Guardian, April 15, 2008, http://www.guardian.co.uk/society/2008/apr/15/health.nhs.

Boseley, Sarah, “Tranquillisers putting children's lives at risk”, The Guardian, April 7, 2008, http://www.guardian.co.uk/society/2008/apr/07/mentalhealth.drugs.

Butki, Scott, “An Unhappy Pharmacy Visit,” Newsvine.com, http://sbutki.newsvine.com/_news/2007/06/29/810673-an-unhappy-pharmacy-visit

Carvel, John, “GPs to provide 5-year health checks for all aged between 40 and 74”, The Guardian, April 2, 2008. http://www.guardian.co.uk/politics/2008/apr/02/health.nhs

Carvel, John, Nurses 'spend 1m hours a week on bureaucracy', The Guardian, April 28, 2008, http://www.guardian.co.uk/society/2008/apr/28/nhs.health.

Carvel, John, “Patients who go to A&E instead of local surgery could cost Gps 1B pounds” http://www.guardian.co.uk/society/2008/apr/17/nhs.health, The Guardian, April 17, 2008.

Chang, Alicia, “Many doctors say L to e-mail”, Chicago Tribune (via AP), April 22, 2008, http://www.chicagotribune.com/news/chi-doctor-emailapr23,0,6511095.story.

“Changes Ahead for Medicare Drug Program,” AP wire story by Kevin Freking, November 4, 2007, http://www.newsvine.com/_news/2007/11/03/1070133-changes-ahead-for-medicare-drug-program?threadId=171361&cmt=1156346#c1156346COBRA law explained: http://www.dol.gov/dol/topic/health-plans/cobra.htm

Coding for billing Acupuncture services, Acupuncture Today, Feb. 2005,
http://www.acupuncturetoday.com/mpacms/at/article.php?id=30032&MERCURYSID=918c70b396ad0a2c4cec8b179efa75c8.

Coding for billing Nutritionist services, please see their 2007 bulletin at . http://www.eatrightnc.org/PDF2007/CodesInsert.pdf

Coding for billing Vitaflo products (enteral and parenteral supplies) at http://www.vitaflousa.com/content.aspx?PFAlias=howtoorderbillingcodesERISA law explained: http://www.dol.gov/dol/topic/health-plans/erisa.htm

Gratzer, David, “The Ugly Truth About Canadian Health Care,” City Journal, Summer 2007, Gratzer is biased against the whole nationalized healthcare concept and has taken aim at the problems of Canadian & other single-payer systems; he proposes vouchers and a two-tier system: http://www.city-journal.org/html/17_3_canadian_healthcare.html

Foster, Kate, “Open all-hours plan for Scottish doctors”, Scotland on Sunday, Feb. 3, 2008, http://scotlandonsunday.scotsman.com/latestnews/Open-allhours-plan-for-doctors.3739044.jp.

Health Symphony, an online resource that includes appeal letters, at http://www.healthsymphony.com/

Health Care Crisis in America, Michael Moore’s appearance on Oprah, 2007, http://www2.oprah.com/world/health/slide/20070927/health_284_101.jhtml

“Health Care Options at a Glance” compares Canada, U.K., France and U.S. systems, Yes Magazine website, http://www.yesmagazine.org/article.asp?ID=1515

The Henry J. Kaiser Family Foundation for reports on a health benefits survey and health care costs at http://www.kff.org/insurance/index.cfm

The Henry J. Kaiser Family Foundation at
http://www.kff.org/uninsured/upload/7651.pdf for a policy brief on Medicaid and the Uninsured, “Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Adults”
Herzlinger, Regina E. , Who Killed Health Care? June 2007 and her article “Who Killed U.S. Medicine?” in the Washington Post July 25, 2007 at http://www.washingtonpost.com/wp-dyn/content/article/2007/07/24/AR2007072401850.htmlHIPAA law explained: http://www.dol.gov/dol/topic/health-plans/portability.htm -- also at HIPAA.org

Holstein, William, “A Drug Maker’s Views of What Ails Health Care”, NY Times, September 8, 2007
http://www.nytimes.com/2007/09/08/business/08interview.html?_r=1&ref=health&oref=slogin

Insurance Transparency Project - All the riveting insurance industry news you can stand, http://insurancetransparencyproject.com/general-theory-of-insurance-transparency/

“Industry wouldn't fund cancer drug, so Alberta town rode to the rescue,” CBC News, October 4, 2007
http://www.cbc.ca/health/story/2007/10/04/fundraising-dca.htmlInsurance coverage for families www.coveringkidsandfamilies.org, from the Robert Wood Johnson Foundation

Insure Kids Now at www.insurekidsnow.gov, where parents click on their state and enroll their children automatically in that state’s children’s health insurance program.

Komen Foundation, Cancer Care Partnership Helps Qualified Patients Meet Some Costs Associated with Breast Cancer Treatment, Assistance Grants ($300) for Medication, Lymphadema Care, Medical Equipm’t, http://cms.komen.org/komen/NewsEvents/KomenNews/CancerCare?ssSourceNodeId=298&ssSourceSiteId=Komen

Krugman, Paul, “Health Care Excuses,” New York Times Op-Ed column, Nov. 9, 2007, http://www.nytimes.com/2007/11/09/opinion/09krugman.html?hpLetters of Medical Necessity, (samples of), see Dr. Bach website at http://www.doctorbach.com/letters/

Meikle, James, “Let dads bond with newborns, says study”, The Guardian, April 14, 2008 http://www.guardian.co.uk/society/2008/apr/14/children.health

Miller, Jennifer, “Federal government taps ancient healing methods to treat native American soldiers,” Christian Science Monitor, Sept. 13, 2007, http://www.csmonitor.com/2007/0913/p20s01-usmi.html

Neergaard, Lauran, “Training Helps Alzheimer's Caregivers,” Washington Post, August 12, 2007, http://www.washingtonpost.com/wp-dyn/content/article/2007/08/12/AR2007081200509_pf.html

Newborns' & Mothers' Protections (Newborns' Act): (Maternity coverage must pay for at least a 48-hr hospital stay.) http://www.dol.gov/dol/topic/health-plans/newborns.htm

Pear, Robert, “Medicare Audits Show Problems in Private Plans,” Oct. 7, 2007, New York Times, http://www.nytimes.com/2007/10/07/us/07medicare.html?_r=1&hp=&adxnnl=1&oref=slogin&adxnnlx=1191729902-/QFjVc2aBDuzO96/FhKk9gPrescription Drugs: What’s the Issue?, an essay on Open Secrets dot org, http://www.opensecrets.org/news/drug/index.htm

Quadragno, Jill, book “One Nation, Uninsured” 2005, published by Oxford University Press. You can read an excellent review of this book on Newsvine on my column. If link does not work use this URL -- http://minnieapolis.newsvine.com/_news/2007/10/27/1054611-one-nation-uninsured-analyzes-a-century-of-failure-to-enact-a-national-health-plan-in-spite-of-public-support-book-review

Ruttley, Marilyn, Henderson hospital threatened with closure - blog, 4-10-08, http://blogs.guardian.co.uk/joepublic/2008/04/vulnerable_people_troubled_by.html.
Slota, Linda, “Training Goes a Long Way for Alzheimer's Spouses” at Christopher Heights.com webpage, http://www.christopherheights.com/page/AlzheimerTraining.cfm

StopHospitalInfections.org. We are all at risk because we cannot judge the relative safety of our hospitals. Consumers Union has developed a selection of Internet-ready public service announcements that can be used to link to StopHospitalInfections.org from any web site. Just click on the links below or scroll down the page to get started. Thanks again for your help!

The Internet Health Library, excellent resource for studies, etc. at http://www.internethealthlibrary.com/

The Medical Insurance Store online -- Includes “Five Ways to Cut Your Health Insurance Costs” & many other topics written at a basic level at http://www.medicalinsurancestore.info/Options%20for%20Those%20Who%20Cannot%20Afford%20Health%20Insurance.php

Pear, Robert, “Medicare Audits Show Problems in Private Plans,” New York Times, October 7, 2007, http://www.nytimes.com/2007/10/07/us/07medicare.html?_r=1&hp=&adxnnl=1&oref=slogin&adxnnlx=1191729902-/QFjVc2aBDuzO96/FhKk9g

Quammen, David, “Deadly Contact: How Animals and Human Exchange Disease,” National Geographic, (unknown date) http://magma.nationalgeographic.com/ngm/2007-10/infectious-animals/quammen-text.html

Sosnowski, Laura A, “Minnesotans Fight Hi Cost of Healthcare With Databases, Walk-in Clinics”, Nov. 2007,
http://minnieapolis.newsvine.com/_news/2007/11/12/1092663-minnesotans-fight-hi-cost-of-healthcare-with-databases-walk-in-clinics#dynamicCommentBox_1180552

Travel insurance website at www.insuremytrip.com. Companies that offer travel insurance are CSA Travel Protection, Access America, and AIG Travel Guard . Carefully compare the terms and conditions of each plan before making your final selection. Check first if you are covered under your credit card or homeowner’s insurance.

Vamosi, Robert, “Security Watch: Spam that just might kill you,” (about fake prescription drugs sold over the Internet) MSN.com, undated, http://tech.msn.com/security/articlecnet.aspx?cp-documentid=5406724&page=1

Whitman, Glen, “Hazards of the Individual Health Care Mandate,” Cato Policy Report, Fall 2007, http://cato.org/pubs/policy_report/v29n5/cpr29n5-1.html

“Why Obama, Edwards, Hillary, Romney, Schwarzenegger Don’t Support Single Payer? It Would Mean the Death of the Health Insurance Industry, and Reduced Profits for Big Pharma,” Corporate Crime Reporter, 1209 National Press Bldg., Washington, D.C. 20045, 202.737.1680, February 21, 2007, http://www.corporatecrimereporter.com/pnhp022107.

Health & Cancer Rights Protections: (Reconstructive surgery is covered as a post-mastectomy benefit.)
http://www.dol.gov/dol/topic/health-plans/womens.htm

“World’s Best Medical Care?”, NY Times editorial, August 12, 2007
http://www.nytimes.com/2007/08/12/opinion/12sun1.html?ei=5124&en=44da5cf6d4bf91c6&ex=1344571200&partner=newsvine&exprod=newsvine&pagewanted=print

MORE ABOUT DENIALS

Sometimes getting a claim paid is like trying to get a promised mail-in rebate. That is, if you had to pay yourself for all the work you had to do to get it, you’d be in negative territory.
The most common reason for denial is: any guesses? It is an incomplete claim.

The insurance company needs what is called a “clean claim.” A clean claim has all the required information on it, your identifying information (like name, address, date of birth, policy number), provider identification (dr. name, address, etc.), the date of service, and information about the service itself (office visit, code, diagnosis code or description). That sounds like a lot, doesn’t it? Not really. All that fits on a standard one-page form called a HCFA (for doctor, clinic, and medical equipment claims), or on a UB-92 (for hospital claims).

Do not give up automatically upon receipt of a denial letter. Often a claim will be resolved without your doing a thing, because a duplicate letter has gone to the provider. The deficiency letter is more likely than not, perfectly intelligible to the billing department, and the followup claim with the requested material is quickly sent by return mail or fax to the insurer. However, the handling of the reply is not handled with the same urgency as the initial claim. If the insurer requests medical records, x-rays, a pathologist report, etc., the process will stretch over a month.

So before launching a full-scale attack on the insurer, please call the provider’s billing department and check if they have received the same letter and what their response will be. If they are already handling it, or if they treat it as a routine matter, you can resume your normal life. If on the other hand they do not deal with insurers, or do not waste energy on appeals, etc., then you will have to go into high gear.

Typically ninety percent of consumers drop their appeals before exhausting their options. According to a study by the Kaiser Family Foundation, 52% of patients won their first appeal for each claim made. If your first appeal gets turned down, make a second appeal because second appeals won 44% of the time. And third appeals won in 45% of cases. There is no reason to give up if you truly believe that your policy covers a given procedure. Follow the instructions for an appeal. An informal appeal is fine for routine services.

First, pull out your denial form or letter and look up what the denial code is and what it denotes. Then pull out your copy of the policy and go through its provisions with a fine toothed comb. It is true that some of the finer points are not given in the copy that you own, such as definitions of terms, or which doctors are in the network, etc. But the insurance laws are such that the policy you have been given, with the application and any riders, constitutes the whole contract between the insurer and you -- (see section on Your Rights As An Insurance Consumer) -- and they cannot add new material wholesale after the fact of granting you coverage. (Language in the contract will refer to providers in the network, and even though the providers are not listed in the contract, this is a valid part of the contract by virtue of being referred to in the section on how payments are calculated.)

So now you have read through your policy and you still feel that your procedure should be covered. Gather together your denial, explanation of benefits, your appt. calendar, any notes you kept on doctor visits and doctor recommendations. This is especially true for emergency visits to the E.R., when they will want to know if you called your doctor’s office and did he/she send you to the emergency room.

Call the insurance company’s customer service line, or go to their website, and make an inquiry as to the exact reason for the denial or why payment is delayed. It may be that the definition of a term is not the same as in ordinary English usage; many definitions are specific to insurance. You should be able to check this information on the insurer’s website, or look up material on the FAQ page of the website. Try asking the customer service rep what the reason is for the denial, and do so politely. The rep may not have that information available yet, as your claim may be stuck in processing. Get a name of a department supervisor and his/her phone number to call next. Then call that person to ask him/her to check into your problem and ask for a followup letter.
The next step is to go online to the NAIC website. This is the National Association of Insurance Commissioners. On the website you can click on a button to contact your state commission. Then you will be able to access a great deal of information about health insurance in general, and about how to proceed in your case. (Your state office will often have email or instant response to your complaint.) Your HMO may also have an appeal task force; ask about the correct procedure to appeal your denial.

Make note of any deadlines for receiving an appeal. If one is given and you are mailing a reply within a week of that deadline, send it certified mail to prove that you met the deadline. Never send originals of insurer paperwork (but keep copies for your file).